We are so proud to feature Stephanie as our newest alum spotlight. She absolutely killed it at interning and is now making a huge difference as a diabetes educator!

We are so proud to feature our alum, Grace, who now works as a Community Wellness Planner. She is making a huge difference in her community through nutrition education! Way to go Grace!

By Cecilia D., Lagniappe Wellness Dietetic Intern

Diabetes mellitus is a disease so common worldwide just about every person walking down the streets of wherever you are reading this from could tell you something about it.  Maybe you have seen commercials on television for medicines to aid in diabetes management, heard the common misconception that carbs are “bad” for people with diabetes, or that celebrities including Nick Jonas and Rosie O’Donnell have diabetes. There are two well studied commonly known variations of diabetes: type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). T1DM is typically diagnosed in children and adolescents; it is an autoimmune disease, which describes an automatic response initiated by the immune system that results in the body’s immune, or “defender” cells, attacking healthy native cells. Often, this attack disrupts a process required for normal bodily functions to occur and keep the individual healthy. In the circumstances of T1DM, the beta cells of the pancreas, which produce insulin, are destroyed by this autoimmune response, and insufficient insulin production results (Nolasco-Rosales et al., 2023). Detection of these autoantibodies are helpful in diagnosing T1DM ( (Nolasco-Rosales et al., 2023)T2DM is developed later on in life usually after the age of thirty, but certainly can be diagnosed in childhood and adolescence. However, in T2DM, insulin resistance is the functional problem and it is perceived as preventable as it is often attributed to the presence of excess adipose tissue, poor diet, and physical inactivity (Nolasco-Rosales et al., 2023). A less commonly known form of diabetes which develops later in life like T2DM, yet presents with similar complications and physical traits to T1DM, is known as latent autoimmune diabetes in adults (LADA) or type 1.5 diabetes mellitus (Buzetti et al., 2020). Some may describe LADA as the most extreme version of T1DM (Nee et al., 2022). LADA is estimated to impact 2-12% of people in the world, but it is speculated the number of afflicted may be even higher as misdiagnosis is likely (Buzzetti et al., 2020).

LADA can be confusing to both professionals and patients and for good reason, too! Part of the confusion has to do with poorly outlined parameters for defining LADA. Inconclusive phenotypic criteria regarding age of detection as over the age of thirty (Lee & Hudda, 2021) or over the age of twenty, thirty, thirty five, or the upper limit of seventy years of age depending on where in the world one may be diagnosed make picking and choosing between a T2DM and LADA diagnosis difficult when primarily concerning age (Chen & Chen, 2019). Thankfully, there are other considerations for diagnosis beyond age. The detection of different autoantibodies which may be present in T1DM, T2DM, and LADA or C-peptide levels which are markedly decreased in both T1DM and LADA (Buzzetti et al., 2020) The presence of C-peptide indicates insulin production, therefore lower C-peptide indicates lower insulin production. Depending on the timing of screening for LADA, use of C-peptide as diagnostic criteria may not be the most accurate marker, especially if the screening is timed between late adolescence and early adulthood when T1DM is most likely to be diagnosed (El Sayed et al., 2023).While insulin resistance is the clear etiology in T2DM and beta cells lacking in numbers and effectiveness due to an autoimmune response is the etiology in T1DM, there is no one key to answer the “Why?” of LADA (Li et al., 2021). Research suggests that LADA diagnosis is associated with less oxidative stress than T2DM, but further analysis and repeat studies must be conducted to solidify this as a risk factor and/or marker with defining ranges of LADA; prevalence of oxidative stress has been well defined in inflammation and related inflammatory conditions including diabetes mellitus, heart diseases, and various cancers (Li et al., 2021). Back in 2016, researchers at AHEPA University Hospital in Thessaloniki, Greece found evidence to suggest combining treatment of sitagliptin with Metformin and vitamin D improved blood sugar control in just 8 weeks in a patient with LADA who had presented with lab values associated with long term relatively poor blood sugar management, thereby preserving remaining beta cell function (Rapti et al., 2016)Researchers and diabetes interventionists have been able to agree on some broad term characteristics of the LADA outlined by Buzzetti and colleagues in 2020, including:

• Insulin is not required for management within at least the first 6 months of diagnosis, but soon after becomes a necessary intervention as beta cells continue to trend down.
• GADA, an autoantibody, is the most sensitive marker for defining LADA. 
• Familial and/or individual history of the diagnosed is positive for autoimmune diseases.

Unfortunately, major barriers to diagnosing LADA lie in the high prices for testing for GADA, serum insulin levels, and C-peptide volume. Additionally, these tests are not commonly available in most clinics, and typically require secondary referrals many patients fail to receive in the first place (Buzzetti et al., 2020). Additionally, LADA is not the type of diabetes at the forefront of the diagnosing practitioner’s mind due to its rarity and novelty in the medical world. It usually requires assertion that some beta-cell function remains and is worthy of preservation. The average practitioner is unlikely to investigate beta-cell functionality when diagnosing a patient beyond the age of thirty, as diagnostic criteria are met with cheaper tests for T2DM, the most common form of diabetes (Buzzetti et al., 2020). This does not mean the physician is not doing her due diligence, rather it means the diagnostic criteria may require changes to include ruling out LADA.Treatment for LADA varies by presence of markers as well. For example, low C-peptide levels may indicate there is no longer beta cell functionality (Buzzetti et al., 2020). Having this marker for reference can be helpful in determining that insulin use is indicated to achieve adequate glycemic control. If C-peptide levels are higher, it may be useful to take the first line of defense in treating T2DM and use Metformin for blood sugar management paired with diet modifications (Buzzetti et al., 2020). The primary goal in LADA management first and foremost is to preserve any remaining beta cell functionality for as long as possible with improved glycemic control, also known as blood sugar management (Buzzetti et al., 2020). Again, if misdiagnosis occurs, it is likely any treatment options will prove to be enough to achieve glycemic control for at least some satisfactory period of time, further masking the true prevalence of LADA. Many motivated researchers are conducting studies about LADA, the diagnostic criteria, gathering evidence to support solidifying standard screening options, and defining treatment objectives to improve the lives of those living with LADA, unbeknownst and aware.LADA is a less common form of diabetes which presents in adulthood with characteristics of T1DM and T2DM such as low C-peptide levels, impaired beta cell function, poor glycemic control, and increased risks for microvascular complications. Definitive tests are often expensive and may lead to misdiagnosis of type 2 diabetes and/or underdiagnosis of LADA. Preventive approaches may be developed with further genetic and familial history analysis. The reason for LADA onset still remains a mystery, but research suggests contributing factors may include, but not be limited to, oxidative stress, vitamin D deficiency, and genetic risk with high prevalence of autoimmune diseases in LADA sufferers families. The best way to improve consistency in diagnostic criteria and treatment options is by getting the word out about the existence of LADA. 

References

Buzzetti, R., Tuomi, T., Mauricio, D., Pietropaolo, M., Zhou, Z., Pozzilli, P., & Leslie, R. D. (2020). Management of Latent Autoimmune Diabetes in Adults: A Consensus Statement From an International Expert Panel. Diabetes, 69(10), 2037–2047. https://doi.org/10.2337/dbi20-0017.

El Sayed, N. A., Aleppo, G.,  Aroda, V. R.,  Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B.S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J.J., Stanton, R. C., Gabbay, R. A.; on behalf of the American Diabetes Association, 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S19–S40. https://doi.org/10.2337/dc23-S002.

Li, J., Zhang, Y., Zhang, J., Dong, R., Guo, J., & Zhang, Q. (2021). Oxidative Stress and Its Related Factors in Latent Autoimmune Diabetes in Adults. BioMed research international, 2021, 5676363. https://doi.org/10.1155/2021/5676363.

Nee, L. Y., Yee, Y. Y., Ci, G. Q., & Voon, T. C. (2022). Type 1 diabetes and latent autoimmune diabetes in adults: Are they the same?. Journal of the ASEAN Federation of Endocrine Societies, 37, 37. Retrieved from https://www.asean-endocrinejournal.org/index.php/JAFES/article/view/2367.

Nolasco-Rosales, G. A., Ramírez-González, D., Rodríguez-Sánchez, E., Ávila-Fernandez, Á., Villar-Juarez, G. E., González-Castro, T. B., Tovilla-Zárate, C. A., Guzmán-Priego, C. G., Genis-Mendoza, A. D., Ble-Castillo, J. L., Marín-Medina, A., & Juárez-Rojop, I. E. (2023). Identification and phenotypic characterization of patients with LADA in a population of southeast Mexico. Scientific reports, 13(1), 7029. https://doi.org/10.1038/s41598-023-34171-2.

Rapti, E., Karras, S., Grammatiki, M., Mousiolis, A., Tsekmekidou, X., Potolidis, E., Zebekakis, P., Daniilidis, M., & Kotsa, K. (2016). Combined treatment with sitagliptin and vitamin D in a patient with latent autoimmune diabetes in adults. Endocrinology, diabetes & metabolism case reports, 2016, 150136. https://doi.org/10.1530/EDM-15-0136.

By: Krista W., Lagniappe Wellness Dietetic Intern

With the continuous rise of obesity rates over the past three decades, it’s no secret that we are in the midst of an obesity epidemic. It is predicted that more than half of the world’s population will be living with overweight or obesity by the year 2035 if no significant action is taken (1). 
The root causes of obesity are complex and go beyond the conventional paradigm of “eat less and move more”. Like any chronic disease, nutrition and exercise are crucial components of a successful treatment plan. However, there are several less-well known factors that can cause unwanted weight gain that also need to be taken into consideration.
Integrative and functional nutrition offers a unique, whole-body approach in identifying and treating the root causes of chronic diseases like obesity and its comorbidities. Because humans are so complex, the idea of a one-size-fits-all solution doesn’t exist, making a whole-body approach critical in modern treatment of obesity and weight management.  

What causes obesity?

Obesity is a multifactorial disease, meaning there are many factors that can have powerful effects on weight management, some of which are outside of a person’s control. While obesity may be the result of chronic energy imbalance caused by excessive calorie intake and physical inactivity, it is not always that simple. 

Genetics and obesity

For the past two decades it has been speculated that obesity is closely related to genetics. In recent years, genome-wide association studies (GWAS) have revealed more than 300 different genes that are linked to body mass index (BMI), waist-to-hip ratio, and other adiposity traits (2). 
For example, obesity is associated with the leptin gene (LEP) and its receptor (LEP-R), both key regulators of adipose tissue and energy balance. Normally, leptin binds to its receptor which triggers a series of chemical signals that help produce a feeling of fullness (satiety). The altered expression (mutation) of these two genes causes a condition known as leptin resistance. With leptin resistance, the brain misses these signals which leads to reduced satiety, over-consumption of nutrients and ultimately weight gain (3). 

Gut health and obesity

The gastrointestinal (GI) tract is home to trillions of bacteria that play a vital role in day-to-day functions including digestion and metabolism of nutrients, immune function and protection against pathogens (4). In order for the body to function optimally, there needs to be a balance between the good and bad bacteria in the gut. 
The composition of the gut microbiome can be affected by several things including genetics, medications, travel, stress, exercise and dietary habits. Evidence shows that those with obesity have an altered gut microbiome, or gut dysbiosis, an imbalance of good and bad bacteria. It has been reported that gut composition differs in obese and lean individuals, further suggesting that gut dysbiosis can affect body weight (5). 
Additionally, gut dysbiosis has been shown to dramatically influence eating behaviors and food preferences. Studies confirm that consumption of highly palatable and ultra-processed food is closely related to gut dysbiosis. This creates a frustrating cycle involving the consumption of the Western diet with poor gut health and “addictive” eating behaviors (6). 

Poor sleep and obesity 

There is extensive evidence linking insufficient sleep to weight gain and obesity. Both poor length and quality of sleep is associated with increased appetite and cravings, and decreased motivation for physical activity. More specifically, sleep deprivation impacts weight maintenance by causing a dysregulation of hunger hormones (leptin and ghrelin) causing an increased sense of hunger, leading to a higher caloric intake (7). Furthermore, a troubling concern for those with obesity is that not only does poor sleep lead to weight gain, but obesity can cause complications like obstructive sleep apnea which affects sleep quality (8).

Stress and obesity

Although it is evident that stress is one of the main factors involved in weight gain and obesity, combating stress is hardly ever part of the conversation for obesity prevention and treatments. Research shows that stress-induced elevated cortisol levels are associated with an increase in appetite and enhanced cravings for highly palatable foods, leading to overconsumption of calories (9). Aside from overeating, stress can also lead to sleep problems, decreased motivation to exercise, increased alcohol consumption and gut dysbiosis, all factors that increase the likelihood of weight gain.

Environmental toxins and obesity 

Scientific evidence shows that certain chemicals that are found in our environment, called obesogens, are linked to weight gain. Obesogens are toxic endocrine-disrupting chemicals (EDCs) that interfere with hormones and disrupt the body’s ability to regulate metabolism and weight (10). The endocrine system is complex and plays a role in many bodily functions by producing, releasing, and regulating various hormones as needed. Hormones that are involved in the control of metabolism and weight include insulin, glucagon and estradiol. 
For example, bisphenol A (BPA), a well-known obesogen commonly found in plastic bottles and food containers, has been shown to interfere with insulin production and sensitivity, and can cause an increase in fat cell production, ultimately increasing the risk of obesity (11). 

Creating a personalized plan for obesity and weight management 

As you can see, there are numerous risk factors that can contribute to unwanted weight gain. This is why it is important to take a personalized, whole-body approach that takes all aspects of an individual into consideration. Along with individualized nutritional recommendations, optimize treatment plans by implementing other lifestyle changes such as:   

Optimize gut health

One way to help restore balance in the gut is by consuming probiotic and prebiotic-rich foods. Probiotics have been shown to improve body composition and reduce body weight, BMI, and abdominal visceral adipose tissue (12). Food sources of probiotics include fermented products like greek yogurt, miso, kimchi and sauerkraut. In order for probiotics to do their job, they need prebiotics to feed off of. Increase dietary prebiotics by consuming more fruits, vegetables, whole grains, beans, lentils and nuts.   
Along with this, limiting stress, alcohol and eating a diet with less ultra-processed foods and added sugars have also been shown to have a positive effect on gut health.  

Get moving  

Exercise has the potential to alleviate many health consequences related to obesity, even in the absence of weight loss. Exercise can not only help increase energy expenditure and reduce excess adipose tissue, but it can also aid in appetite regulation and restore insulin sensitivity (13). 
The most appropriate exercise plan is one that is customized to an individual and includes all aspects of physical fitness including strength training, cardiovascular and flexibility exercises. As a general goal, aim for 150 minutes of moderate-intensity exercise per week.  

Stress management

Reducing stress will not only have a positive effect on body composition, but also on one’s overall well-being (14). Stress-relieving activities are infinite and may include gentle exercise, journaling, meditating, listening to music, bubble baths, reading a book or spending time in nature. 
Another way to reduce stress is through connecting with others. Having a community to rely on helps create a sense of belonging, protecting against stress, depression and anxiety. Bonds can be built with existing family or friends, or with new groups of people through volunteering or book clubs. 

Get better sleep  

In efforts to optimize health and metabolism, getting enough quality sleep is crucial. Ways to get better sleep include implementing a sleep schedule of no less than 8 hours per night, following a bedtime routine to help wind down, creating a comfortable sleeping environment and engaging in healthy habits like exercise during the day. 
Additionally, try not to consume food within three hours of bedtime as sleep quality may be affected (15). 

Reduce toxin exposure  

Unfortunately, a consequence of living in an industrialized society is the abundance of  obesogens in the environment. Some ways to minimize exposure of obesogens linked to weight gain include (16): 

• Replace non-stick cookware with stainless steel or glass
• Heat and store foods in glass containers instead of plastic 
• Swap harsh cleaning products for natural ones such as vinegar and baking soda
• Invest in a home air purifier  
• Filter tap water 
• Choose fragrance-free beauty products and detergents

ConclusionObesity is a worldwide health concern that is continuing to rise rapidly. Integrative and functional nutrition recognizes that weight gain and obesity have deep-rooted causes that simply cannot be corrected by calorie restriction and exercise alone. It’s crucial that treatment plans consider all factors that contribute to weight gain including energy imbalance, genetic alterations, gut dysbiosis, poor sleep and stress management, and environmental impacts. A functional approach that includes the conventional wisdom of diet and exercise, but goes a step further to individualize a custom plan based on these risk factors is key to reversing the current obesity trend.by Krista Wale, LWDI Intern 

References 

1. World Obesity Federation, World Obesity Atlas 2023. https://data.worldobesity.org/publications/?cat=19
2. Goodarzi, M. (2017). Genetics of obesity: what genetic association studies have taught us about the biology of obesity and its complications. Lancet Diabetes Endocrinol. 6(3), 223-236. https://doi.org/10.1016/S2213-8587(17)30200-0
3. Obradovic, M., Sudar-Milovanovic, E., Soskic, S., Essack, M., Arya, S., Stewart, A. J., Gojobori, T., & Isenovic, E. R. (2021). Leptin and Obesity: Role and Clinical Implication. Frontiers in endocrinology, 12, 585887. https://doi.org/10.3389/fendo.2021.585887
4. Rinninella, E., Raoul, P., Cintoni, M., Franceschi, F., Miggiano, G. A. D., Gasbarrini, A., & Mele, M. C. (2019). What is the Healthy Gut Microbiota Composition? A Changing Ecosystem across Age, Environment, Diet, and Diseases. Microorganisms, 7(1), 14. https://doi.org/10.3390/microorganisms7010014 
5. Cuevas-Sierra, A., Ramos-Lopez, O., Riezu-Boj, J. I., Milagro, F. I., & Martinez, J. A. (2019). Diet, Gut Microbiota, and Obesity: Links with Host Genetics and Epigenetics and Potential Applications. Advances in nutrition (Bethesda, Md.), 10(suppl_1), S17–S30. https://doi.org/10.1093/advances/nmy078
6. Novelle M. G. (2021). Decoding the Role of Gut-Microbiome in the Food Addiction Paradigm. International journal of environmental research and public health, 18(13), 6825. https://doi.org/10.3390/ijerph18136825
7. Papatriantafyllou, E., Efthymiou, D., Zoumbaneas, E., Popescu, C. A., & Vassilopoulou, E. (2022). Sleep Deprivation: Effects on Weight Loss and Weight Loss Maintenance. Nutrients, 14(8), 1549. https://doi.org/10.3390/nu14081549
8. Seo, S. H., & Shim, Y. S. (2019). Association of Sleep Duration with Obesity and Cardiometabolic Risk Factors in Children and Adolescents: A Population-Based Study. Scientific reports, 9(1), 9463. https://doi.org/10.1038/s41598-019-45951-0
9. Hewagalamulage, S. D., Lee, T. K., Clarke, I. J., & Henry, B. A. (2016). Stress, cortisol, and obesity: a role for cortisol responsiveness in identifying individuals prone to obesity. Domestic animal endocrinology, 56 Suppl, S112–S120. https://doi.org/10.1016/j.domaniend.2016.03.004
10. Jackson, E., Shoemaker, R., Larian, N., & Cassis, L. (2017). Adipose Tissue as a Site of Toxin Accumulation. Comprehensive Physiology, 7(4), 1085–1135. https://doi.org/10.1002/cphy.c160038
11. Naomi, R., Yazid, M. D., Bahari, H., Keong, Y. Y., Rajandram, R., Embong, H., Teoh, S. H., Halim, S., & Othman, F. (2022). Bisphenol A (BPA) Leading to Obesity and Cardiovascular Complications: A Compilation of Current In Vivo Study. International journal of molecular sciences, 23(6), 2969. https://doi.org/10.3390/ijms23062969 
12. Cerdó, T., García-Santos, J. A., G Bermúdez, M., & Campoy, C. (2019). The Role of Probiotics and Prebiotics in the Prevention and Treatment of Obesity. Nutrients, 11(3), 635. https://doi.org/10.3390/nu11030635
13. Kullmann, S., Goj, T., Veit, R., Fritsche, L., Wagner, L., Schneeweiss, P., Hoene, M., Hoffmann, C., Machann, J., Niess, A., Preissl, H., Birkenfeld, A. L., Peter, A., Häring, H. U., Fritsche, A., Moller, A., Weigert, C., & Heni, M. (2022). Exercise restores brain insulin sensitivity in sedentary adults who are overweight and obese. JCI insight, 7(18), e161498. https://doi.org/10.1172/jci.insight.161498
14. Xenaki N, Bacopoulou F, Kokkinos A, Nicolaides NC, Chrousos GP, Darviri C. Impact of a stress management program on weight loss, mental health and lifestyle in adults with obesity: a randomized controlled trial. J Mol Biochem. 2018;7(2):78-84. 
15. Chung, N., Bin, Y. S., Cistulli, P. A., & Chow, C. M. (2020). Does the Proximity of Meals to Bedtime Influence the Sleep of Young Adults? A Cross-Sectional Survey of University Students. International journal of environmental research and public health, 17(8), 2677. https://doi.org/10.3390/ijerph17082677

Wu, Bangsheng et al. “Using three statistical methods to analyze the association between exposure to 9 compounds and obesity in children and adolescents: NHANES 2005-2010.” Environmental health : a global access science source vol. 19,1 94. 31 Aug. 2020, doi:10.1186/s12940-020-00642-6

By Maddie B., Lagniappe Wellness Dietetic Intern

What is an Eating Disorder?
Eating Disorders (ED) are serious mental health disorders that can detrimentally affect physical health if left untreated. Two specific diagnoses, Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are generally well-known and more common diagnoses — and are most commonly associated with fear of weight gain and distorted body image.
Anorexia is characterized by active restriction and control of food intake, while Bulimia presents differently and is commonly recognized by purging behaviors. These behaviors include or can be a combination of self-inflicted vomiting, excessive exercise, or abuse of medications such as laxatives or diet pills, with the intention to lose weight or change one’s body.¹
Eating disorders are unique to each person and can present in a number of ways; it is unrealistic to fit such a complex mental health disorder into two monolithic boxes. A variety of diagnoses have become more prevalent and have contributed to new practice in how eating disorders are treated. Other eating disorder diagnoses that are gaining more awareness include: Binge Eating Disorder, Avoidant-Restrictive Food Intake Disorder, and Other Specified Feeding or Eating Disorder. The emergence of a variety of diagnoses helps to specify the most ideal treatment path for each individual based on how their eating disorder presents and what their individual needs are to promote healing.²
Eating Disorders with Type 1 Diabetes Mellitus (ED-T1DM)
Those living with Type 1 Diabetes Mellitus (T1DM) are at an increased risk for developing an eating disorder due to the constant attention to food and diet that coincides with T1DM management. This attention to food intake, blood sugar levels, and carbohydrate counting can lead to a need to reclaim control in their diabetes and strive for a certain level of perfection in diabetes management.^1,3
People living with T1DM may also experience anxiety or depression associated with living with a chronic disease. The non-clinical term “diabulimia” has been coined for eating disorders that are comorbid with T1DM. Diabulimia is characterized by the intentional neglect or avoidance of insulin treatment with intention to lose or control weight.^3,4 Like any other eating disorder, it can manifest differently in each individual’s behavior. Someone suffering from this condition may still actively eat food, but may restrict their insulin as a form of purging. Others may actively restrict their food and their insulin. Since “diabulimia” has not yet become an official diagnosis, patients may be diagnosed with ED-T1DM, a non-specific diagnosis, or in more extreme cases, may just be classified as neglecting DM treatment, where mental health will not be addressed. The lack of official diagnosis and understanding for this condition leaves many untreated or receiving subpar care for their disorder.⁵ People with T1DM and diabetes-related disordered eating are living with continuously elevated blood sugar levels, which can lead to irreversible physical damage or even death. Diabulimia is not only a mental health disorder, but also an uncontrolled chronic disease, which, in combination, is more detrimental and dangerous and must be treated as such.³

Identifying “Diabulimia”
Due to eating disorders being a multifaceted condition, each person’s symptoms may present differently. Below are warning signs to help identify if your client or loved one may be experiencing “diabulimia”:^3,5

• Increased negligence of diabetes management
• Avoidance of discussion of diabetes management
• Extreme changes in dietary intake
• Isolation from social eating, ex: skipping family meals, eating alone, avoiding eating out
• Irrational fear of low blood sugar levels
• Increased concern with body image
• Avoiding diabetes related appointments
• Increased fatigue
• Testing blood sugar levels in secrecy 
• Obsession with food and/or body weight
• Excessive exercise
• Depression 
• Anxiety

Alongside behavioral changes, there are physical changes that may also help to identify this condition:^3,5

• Excessive thirst
• Frequent urination
• Sudden, unexplained weight loss
• Frequent nausea or vomiting
• Consistent Hemoglobin A1C levels of 9.0 or higher
• Frequent Diabetic Ketoacidosis episodes
• Dry hair, skin, nails
• Extreme fatigue
• Vision complications
• Irregular periods in menstruating people
• Bladder or yeast infections

Health Concerns in the Long Term
In a person with T1DM, without insulin, glucose cannot enter the cells, thus preventing weight gain — this may sound ideal and an easy weight loss solution to the person with the eating disorder. In turn, this person restricting their food or insulin is living with extreme prolonged elevated blood glucose levels. The risks associated are parallel to the risks associated with poor management or neglect of T1DM management and range, from nerve damage, to cardiovascular complications, or even death.^3,4
Individuals with diabulimia may have frequent episodes of Diabetic Ketoacidosis (DKA) a diabetic complication associated with lack of insulin, leading to detrimental, irreversible health effects such as kidney damage, vision loss, or swelling of the brain. Serious nutritional deficiencies and electrolyte imbalances can lead to organ failure.^3,4 The combination of a mental health disorder with a chronic disease like Diabetes increases the danger of this eating disorder and cannot be treated in the same manner that health professionals treat Anorexia or Bulimia.3 
Seeking Treatment and the Importance of Multidisciplinary Support
A multidisciplinary team is the ideal treatment structure for a person with an eating disorder. This team usually includes a physician, a registered dietitian, and a mental health specialist. The unique diagnosis of an eating disorder co-occurring with T1DM should include a treatment team that is just as specialized as the diagnosis at hand. A successful treatment for diabulimia must reflect both mental health support and physiological treatment. While the ideal physician would specialize in diabetes care as an endocrinologist, an ideal registered dietitian would be a certified diabetes educator, and a qualified therapist would be one who specializes in eating disorders. Along with a treatment team, a support system of loved ones can significantly enhance the healing process. If a higher level of care is necessary, it is crucial to find a facility that has robust experience in treating diabulimia.³
Advocacy for Awareness and Education
Increasing research and awareness of eating disorders associated with T1DM is extremely important to providing well-rounded care to patients due to the extreme health concerns associated. The non-clinical term “diabulimia” is being embraced more in health professions, and the understanding of this disorder may help to diagnose and treat individuals on a greater scale. Diabulimia is not simply neglect of diabetes management, it is a serious mental health concern that needs to be advocated for and included in the education of health professionals.¹

References:

1. Coleman, S. E., & Caswell, N. (2020, September 23). Diabetes and eating disorders: An exploration of “Diabulimia.” BMC psychology. https://pubmed.ncbi.nlm.nih.gov/32967730/ 

2. Treasure, J., Hübel, C., & Himmerich, H. (2022, January 11). The evolving epidemiology and Differential Etiopathogenesis of eating disorders: Implications for prevention and treatment. World psychiatry : official journal of the World Psychiatric Association (WPA). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8751578/ 

3. Hall, R., Keeble, L., Sünram-Lea, S.-I., & To, M. (2021, June 13). A review of risk factors associated with insulin omission for weight loss in type 1 diabetes. Clinical child psychology and psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264633/ 

4. Monte Nido. (2022, October 27). Diabulimia: The dangerous condition that doesn’t get enough attention. Monte Nido. https://www.montenido.com/diabulimia-dangerous-condition/ 
5. Diabulimia. National Eating Disorders Association. (2018, February 21). https://www.nationaleatingdisorders.org/diabulimia-5#:~:text=Diabulimia%20does%20not%20have%20a,is%20binging%20then%20restricting%20insulin.

By: Jeanette A., Lagniappe Wellness Dietetic Intern

In today’s fast-paced world, the prevalence of obesity and diabetes has reached alarming levels. While medical interventions and dietary changes play crucial roles in managing these conditions, there is another vital aspect that often goes unrecognized—the impact of trauma on individuals’ health. Trauma-informed care has emerged as a paradigm shift in healthcare, highlighting the need to acknowledge and address trauma when providing treatment. In this blog, we aim to raise awareness among registered dietitians and the general population about the importance of trauma-informed care in obesity and diabetes management.

Understanding Trauma and Its Connection to Obesity and Diabetes

Trauma refers to an overwhelming experience or event that exceeds an individual’s ability to cope. Adverse childhood experiences (ACEs), such as abuse, neglect, or household dysfunction, can have long-lasting effects on physical and mental health. Research has shown a strong link between trauma and the development of obesity and diabetes later in life. Chronic stress from trauma can disrupt hormonal regulation, increase inflammation, and impair metabolic function, all of which contribute to the development of these conditions.¹

The Role of Trauma-Informed Care

Trauma-informed care recognizes the impact of trauma on an individual’s well-being and aims to create a safe and supportive environment that promotes healing and recovery. By integrating trauma-informed approaches into obesity and diabetes care, registered dietitians can better understand and address the underlying factors influencing their patients’ health. Here are key principles to consider from the Center for Health Strategies:²

• Safety: Prioritize physical and emotional safety by creating a non-judgmental and supportive space for patients to share their experiences and concerns.
• Trustworthiness and Transparency: Build trust through clear communication, respect for autonomy, and involving patients in shared decision-making regarding their treatment plans.
• Peer Support: Individuals with lived trauma experiences who receive specialized training can effectively engage with patients by building trust and promoting treatment participation, offering a powerful tool to combat the isolation often experienced by trauma survivors.
• Collaboration: Foster a collaborative partnership between the dietitian and the patient, recognizing the patient as an expert in their own lived experiences.
• Empowerment: Support patients in developing a sense of control and empowerment over their health by providing education, tools, and resources.
• Cultural Sensitivity: Be mindful of diverse backgrounds and experiences, recognizing the influence of culture, race, and socioeconomic factors on health outcomes.

Practical Strategies for Trauma-Informed Care in Obesity and Diabetes Management

Registered dietitians can integrate trauma-informed care principles into their practice to provide comprehensive care for patients with obesity and diabetes. Here are some practical strategies³:

• Conduct Trauma Screening: Include trauma screening as part of the initial assessment to identify patients who may have experienced trauma.
• Foster Emotional Well-being: Incorporate mindfulness techniques, stress reduction strategies, and counseling referrals to address emotional distress and promote self-care.
• Individualize Treatment Plans: Tailor dietary recommendations and lifestyle interventions to meet patients’ unique needs, preferences, and abilities.
• Address Food-Related Trauma: Understand the relationship between trauma and food, addressing any disordered eating behaviors or emotional eating patterns.
• Collaborate with a Multidisciplinary Team: Work closely with psychologists, therapists, social workers, and other healthcare providers to provide holistic care and support.

Trauma-informed care is a crucial aspect of obesity and diabetes management that should not be overlooked. By adopting a trauma-informed approach, registered dietitians can help patients address the underlying causes of their health conditions and support their healing journey. 

A case study illustrates how trauma-informed care improved glycemic control for an individual with diabetes.4 Examples of trauma-informed interventions align with standards of care in Diabetes and nutrition therapy goals.⁵ By incorporating trauma-informed care into obesity and diabetes treatment, we can address underlying trauma and facilitate transformative healing. Furthermore, raising awareness about trauma-informed care among the general population can encourage a more compassionate and empathetic society where individuals are understood and supported in their health challenges. Let us join hands to foster healing, resilience, and well-being in pursuing better health for all.

Works Cited

1. Carrie Dennett, M. R. (2021). Trauma-Informed Nutrition Care. Today’s Dietitian, 36.
2. Mason, S. M., Austin, B. S., Bakalar, J. L., Boynton-Jarrett, R., & Field, E. A. (2016). 
3. Child Maltreatment’s Heavy Toll: The Need for Trauma-Informed Obesity Prevention. Psychology: Faculty Publications.
4. Meadows, A. L., & Marsac, M. L. (2020). Early-Life Trauma and Diabetes Management: An Under-Recognized Phenomenon in Transition-Aged Youth. National Library of Medicine, 93-95.
5. Menschner, C., & Maul, A. (2016, April). Key Ingredients for Successful Trauma-Informed Care Implementation. Retrieved from samhsa: samhsa.gov

By: Reuben R., Lagniappe Wellness Dietetic Intern

The world of dietetics is constantly evolving. Newly emerging research on how nutrients impact our bodies and health is constantly scrutinized and the efficacy of new diets regularly discussed. Macronutrient ratios, meal timing, food composition, weight cycling, meat or meatless, organic or GMO—all topics endlessly discussed to find an eating pattern which will achieve maximum health for our patients, clients, and communities. What is not frequently discussed, however, is how we communicate and form relationships with our patients and how it impacts their health and lifestyle.

As a community of experts, if we could develop the best diet, complete with a comprehensive list of micronutrients and food properties, it would mean nothing if we could not communicate the idea with the public and would have no value if we could not develop meaningful and impactful relationships with patients. An analysis published in the International Journal of Preventive Medicine found that self-body perception, self-motivation, and behavioral improvements were key drivers in helping people lose weight and keep it off.¹ In other words, successful weight loss had more to do with factors related to intrapersonal skills and abilities than a specific methodology of eating. Yet, our conversations in dietetics still revolve almost entirely around the latter. Much to the detriment of our profession—and to the health of our patients—not enough time has been spent on creating effective methods of empowering clients.

  This reality is playing out in front of us now. We know more about food, nutrition, and its impact on human physiology than ever before, yet more Americans are obese and suffering from largely preventable chronic diseases such as cardiovascular disease and type 2 diabetes.² The problem that we face now as a profession is not a lack of information, but rather, barriers to implementation.

One possible method to help us close this gap is Motivational Interviewing (MI). Originally pioneered by William Miller in the 1980s to help individuals break the cycle of substance abuse, motivational interviewing takes a patient centered approach with an eye toward facilitating behavior change. Research from the early 1980s showed that, “therapist empathy during treatment predicted a surprising two-thirds of the variance in client drinking 6 months later” and that the “alcoholism counselors’ client-centered interpersonal functioning accounted for a substantial proportion of variance in the relapse…of assigned clients.” Findings such as these combined with collaboration with other colleagues in his field led Miller to develop a framework for what eventually came to be called Motivational Interviewing.³

Behind the technical aspects of implementing Motivational Interviewing lies the spirit of MI—the foundational tenets that the other portions of the technique are built upon. The Motivational Interviewing Network of Trainers outlines the spirit of MI as follows:

MI is practiced with an underlying spirit or way of being with people:

o   Partnership. MI is a collaborative process. The MI practitioner is an expert in helping people change; people are the experts of their own lives.

o   Evocation. People have within themselves resources and skills needed for change. MI draws out the person’s priorities, values, and wisdom to explore reasons for change and support success.

o   Acceptance. The MI practitioner takes a nonjudgmental stance, seeks to understand the person’s perspectives and experiences, expresses empathy, highlights strengths, and respects a person’s right to make informed choices about changing or not changing.

o   Compassion. The MI practitioner actively promotes and prioritizes clients’ welfare and wellbeing in a selfless manner. ⁴

Stemming from this “way of being with people” flows the processes and core skills utilized to help evoke patient centered change.

Over 1,000 peer-review articles have been published exploring the impact of Motivational Interviewing.⁵ In its original arena of helping to treat substance abuse, research points to higher retention rates in treatment as well as close to double to the rates of abstinence from alcohol or drugs compared to controls in some studies. Additionally, MI was even more effective when combined with other treatments or interventions.³ This may be attributed to the fact that Motivational Interviewing is really more “a method of communication rather than intervention, sometimes used on its own or combined with other treatment approaches.” ⁴ Although substance abuse and poor dietary patterns produce different consequences for patients, interventions for both have the same underlying goal in mind—changes in behavior designed to improve patient outcomes. This lies directly within the main strength of motivational interviewing, something which makes it a prime candidate to be co-opted into dietetics professional practice. The synergistic effect of MI when combined with other interventions means that dietetics professionals can combine the core concepts of MI with other validated tools like nutrition education to help empower and improve patient outcomes.

Although not as widely studied in the discipline of nutrition when compared to other areas, studies that have investigated MI on nutrition-related diseases and topics have found that it can help lower HgA1c in type 2 diabetics (see table), increase weight loss compared to controls, and assist in improving health related lifestyle factors such as exercise.^{6, 7, 5} 

Nutrition professionals need to continue to explore how Motivational Interviewing can improve our ability to reach patients.  Beyond that, we need to understand that our relational skills are as important as our technical ones and need to be evaluated, refined, and tested with the same eagerness. We need to take time to understand and explore emerging research on communication methods and techniques and how they can apply to our practice. Dietetics is more than nutrition—it is a field centered around the good of the patient and as such, it is our responsibility to capitalize on any tool available that will make us more effective practitioners and lead patients to happier and healthier outcomes.

References

Gupta, H. Barriers to and facilitators of long term weight loss maintenance in adult UK people: A thematic analysis. Int J Prev Med. 2014 Dec; 5(12). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336981/ Published December 2014.

About Chronic Diseases. Center for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/about/index.htm. Last updated July 21, 2022. Accessed December 2022.

Rose, G. Miller, W. Toward a theory of motivational interviewing. Am Psychol. 2009 September ; 64(6): 527–537. doi:10.1037/a0016830. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759607/pdf/nihms146933.pdf

Understanding motivational interviewing. Motivational Interviewing Network of Trainers. https://motivationalinterviewing.org/understanding-motivational-interviewing. Accessed December 2022

What is motivational interviewing. USDHHS. https://eclkc.ohs.acf.hhs.gov/mental-health/article/what-motivational-interviewing#:~:text=Q%3A%20What%20is%20the%20evidence,studies%20 published%20on%20 motivational%20 interviewing. Last updated September 22, 2022. Accessed December 2022.   

Berhe, K. Gebru, H. Kaysay, H. et. al. Effect of motivational interviewing intervention on HbA1C and depression in people with type 2 diabetes mellitus (systematic review and meta-analysis). PLoS One. 2020; 15(10): e0240839. Published online 2020 Oct 23. doi: 10.1371/journal.pone.0240839. Published  

Welch, G. Rose, G. Ernest, D. Motivational nterviewing and iabetes: What is it, how is it used, and does it work?Diabetes Spectr 2006;19(1):5–11

By Mara B., Lagniappe Wellness Dietetic Intern

On January 10th, 2020 the covid-19 outbreak was announced in Wuhan, China. By March and April, the “world [began] to shut down” (2). This closure brought about drastic changes such as school closures which forced children to stay home. Because of the shelter in place, children had fewer opportunities for physical activity, less access to balanced meals, and disrupted daily routines, among other detrimental outcomes. As a result of this, rates of childhood obesity have increased. 

As we address the covid-19 pandemic, it is important to discuss the epidemic of childhood obesity. Currently, 1 in 5 children are affected by childhood overweight and obesity. More than 30% of children are now considered to be overweight or obese (6). The Centers for Disease Control (CDC) and Prevention define overweight as 85-94 percentile of the CDC sex-specific weight for age growth charts. Obesity is considered to be within the 95-98 percentile and extreme obesity is classified as anything greater than the 99th percentile. 

Covid-19 and obesity overlap as obesity is a risk factor for increased severity of covid-19. Both diseases are influenced by ecological and biological factors. The figure below outlines how environmental factors such as an obesogenic environment, less physical activity, and weight bias/stress affect obesity (1). In comparison, environmental impacts from covid-19 such as shelter-in-place orders, decreased physical activity, and disruptions in the household can have deleterious outcomes for children. Additionally, a person’s genetics also impacts how both diseases affect children. Both obesity and covid-19 can alter the immune response, lead to states of stress, and cause inflammation. 

An important implication of school closures was that children wouldn’t have access to balanced meals provided throughout the school day. During the pandemic, many families experienced food insecurity. Food insecurity is defined as the “consistent lack of food to live a healthy life because of your economic situation”. Some parents were laid off from work meaning less money for groceries. As a result, cheaper foods high in calories and low in nutrients may have been more affordable options for families suffering from food insecurity. These cheaper food options put children at higher risk for obesity. The National School Lunch Program emphasizes the importance of incorporating meats/meat alternates, fruits/vegetables, grains, and fluid milk. The program has daily and weekly requirements for each food group to ensure children are receiving proper nutrition for their age group and reducing the risk of chronic diseases (4). Some families may not have the proper nutrition education required to provide balanced meals for their children especially when income is reduced. Proper nutrition is essential for growing children and should be of high importance to pediatricians as well. In order to create change, nutrition education should be a covered service for families to support the development of their children. 

Programs such as the Women, Infants, and Children (WIC) program can help families receive nutrition education and supplemental food assistance. The program is designed for pregnant moms and children up to the age of 5. However, during the pandemic enrollment for WIC only increased by about 2-3%. Participation in the program has been steadily decreasing within the past decade and did not drastically increase during the pandemic despite the need for supplemental assistance for families. Currently, WIC is trying to make enrollment and continued participation as easy and convenient as possible for families. The program is pushing for more video appointments making nutrition education more accessible for families. This “modernization” of WIC helps retain participants and supply supplemental assistance for children to have increased access to healthy foods (5). The WIC program also focuses on anthropometric data such as body mass index (BMI) and height to identify overweight, obesity, and proper growth in children. Referrals to WIC are of the utmost importance to support this valuable program and its efforts to reduce childhood obesity. Advocating for WIC by going to their website for advocacy https://www.nwica.org is also a great way to support the program. 

Physical activity in children was also significantly reduced as a result of school closures. Children were forced to stay home during the pandemic which reduced the amount of hours spent outdoors (3). With more time spent indoors the amount of screen time increased. It has also been noted that some children do not have access to a green area where they can exercise. Limited play area has been seen to disproportionately affect low-income populations as their households may be smaller meaning less space for children to play. Most children also began remote or hybrid schooling where their physical activity was done remotely during the day. However, not all households may have an area where physical activity can be done comfortably. Limited access to an environment conducive to movement increases a child’s risk for obesity. Providing education to parents on physical activity requirements, ideas for movement, and using daily child exercise videos can help get their children to be more active and reduce their risk for obesity. 

Clearly, the effects of the covid-19 pandemic have superimposed the epidemic of child obesity. Extended periods of isolation from school and social interaction have had lasting implications on the rates of child obesity. Consequences of covid-19 discussed for children include reduced access to healthful meals, less opportunity for movement, food insecurity, and immune system suppression. Children are one of the most vulnerable populations. For this reason, it is important to advocate for them by providing education on nutrition and physical activity to parents. Additionally, promoting community programs such as WIC provides supplemental assistance to families to reduce food insecurity. These strategies can lower rates of obesity in children to allow them to live a healthy balanced life.  

References:

1. Browne, Nancy T, et al. “When Pandemics Collide: The Impact of Covid-19 on Childhood Obesity.” Journal of Pediatric Nursing, U.S. National Library of Medicine, 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657263/.
2. Katella, Kathy. “Our Pandemic Year-A Covid-19 Timeline.” Yale Medicine, Yale Medicine, 9 Mar. 2021, https://www.yalemedicine.org/news/covid-timeline. 
3. Covid-19 and childhood obesity – researchgate.net. (n.d.). Retrieved December 31, 2022, from https://www.researchgate.net/profile/Ray-Marks/publication/359601351_COVID_19_AND_CHILDHOOD_OBESITY/links/6244aab17931cc7ccf0603a9/COVID-19-AND-CHILDHOOD-OBESITY.pdf
4. FNS nutrition programs. Food and Nutrition Service U.S. Department of Agriculture. (n.d.). Retrieved December 30, 2022, from https://www.fns.usda.gov/programs
5. USDA makes major investments in WIC to improve maternal and child health. Food and Nutrition Service U.S. Department of Agriculture. (2022, October 19). Retrieved December 30, 2022, from https://www.fns.usda.gov/news-item/usda-0224.22
6. “Childhood Overweight & Obesity.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 1 Apr. 2022, https://www.cdc.gov/obesity/childhood/index.html.